11 Forensic psychiatry11.1 Crime and mental disorder
11.1.4 Victimisation, vulnerability and psychiatric consequences
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Written by Resident Doctor Committee · Published
Who is vulnerable
People with severe mental illness are highly vulnerable: in one US study over a quarter reported violent victimisation in a year, about eleven times the comparison rate.
Abuse of people with intellectual disability usually involves someone they know, such as a relative, a carer or another service user.
A psychiatric diagnosis must never be used to dismiss a disclosure.
Stalking
Stalking is unwanted pursuit of someone who is trying to avoid contact.
Mullen's typology
Mullen classifies stalkers into five types by motive and by their prior relationship with the victim.
Type | Target and motive | Distinguishing points |
|---|---|---|
Rejected | Former intimate partner; swings between pleas for reconciliation and threats of revenge | Commonest type; among the most likely to assault |
Intimacy seeker | Someone, often a stranger, believed to return their love | Includes people with erotomanic delusions; hard to deter through the courts |
Incompetent suitor | Wants a date; poor social skills and a sense of entitlement | Pursues briefly, often stops when firmly refused, then picks a new target |
Resentful | Lasting grievance; casts themselves as the wronged party | Aims to frighten the victim |
Predatory | Covertly watches a stranger to prepare a sexual attack | Rarest type; often paraphilia or previous sexual offending; most associated with sexual assault |
Risk of violence
A former intimate relationship with the victim is the strongest and most consistent predictor of physical violence.
Psychosis, a stranger relationship and higher education are associated with lower risk.
About half of stalkers who threaten violence go on to act on the threat.
When stalking is delusionally driven, the commonest content is erotomanic delusion.
Stalking of psychiatrists
In the Royal College of Psychiatrists member survey, about one in ten had been stalked and about three in ten harassed, mostly by patients.
General adult psychiatrists are the specialty most often stalked by patients or their relatives, ahead of medical psychotherapy.
Domestic abuse and sexual violence
Coercive control is the UK term for a sustained, threat-backed pattern of domination in an intimate or family relationship: isolation, economic control, removal of independence and regulation of daily life.
Coercive control is domination within a relationship, whereas stalking is pursuit of someone trying to avoid contact.
Domestic abuse is most often committed by a man against a female current or former partner, but men make up 30 to 35% of adults experiencing it each year.
Fewer than a quarter of victims, around one in five in UK survey data, tell the police.
Violence at home against women and children rose during the COVID-19 pandemic, driven by household stressors.
Most rape victims of either sex know the perpetrator, but strangers make up a larger share of assaults on men.
A current or former partner is the offender most often named by victims of rape or assault by penetration, and strangers are a minority.
Psychiatric consequences
Diagnosis | Core features | Course |
|---|---|---|
Acute stress reaction | Transient response to extreme stress; outside the ICD-11 mental disorders chapter | Begins quickly, usually settles over days |
Post-traumatic stress disorder (PTSD) | Re-experiencing in the present, avoidance and current threat (hypervigilance, exaggerated startle), with impairment | At least several weeks |
Complex PTSD | PTSD plus affect dysregulation, negative self-concept and relationship difficulties | Usually follows prolonged or repeated trauma, such as captivity, trafficking or domestic abuse |
ICD-11 PTSD needs all three core clusters, and prolonged trauma alone does not make the diagnosis of complex PTSD.
Evidence and credibility
Inconsistency in a traumatic account does not prove it false, and consistency does not prove it true.
The court decides credibility, so the psychiatrist describes symptoms but does not certify that a complainant is truthful.
A compensation claim neither proves nor disproves genuine symptoms, whereas malingering is intentional fabrication or exaggeration for an external incentive.
Treatment and support
NICE recommends trauma-focused psychological therapies; adults who prefer medication may be offered a selective serotonin reuptake inhibitor or venlafaxine.
Sexual Assault Referral Centres provide medical and forensic care, and Independent Sexual Violence and Domestic Violence Advisers support safety and the justice process.